Suicide – Is CBT the answer? A practical look at CBT

beppe-micallef-trigona-cbt-suicide

An Introduction

Cognitive-behavioural therapists use a variety of techniques in their work with suicidal patients. The choice of technique depends on various factors including: the patient’s psychological capacity, the nature of the problem in question as well as the psychological model that the therapist has determined to be most relevant to the patient’s problems. The cognitive-behavioural formulation is based on information derived from the first assessment. It should be a written explanation of the problem that sheds light on the crucial factors, both cognitive and behavioural, which are thought to play a role in the development and maintenance of the suicidal behaviour. It should also reflect the role of external factors, such as family problems or problems with peers, as well as the patient’s views of themselves and of their world. It is possible that the formulation may elucidate various treatment options, but either way, the creation of a formulation is an essential part of cognitive- behavioural therapy with suicidal patients.

Problem Solving

A key ingredient of the cognitive-behavioural approach to suicidal behaviour is problem solving. Although the immediate antecedents of many episodes of suicide are often identifiable in specific cognitions or emotions, the trigger is usually caused by some external problem. These problems are usually interpersonal in nature, and involve both family and peers. Training in problem solving helps patients cope with external challenges, and also provides a useful model for a cognitive-behavioural approach.

Cognitive Techniques

At the centre of the cognitive approach with suicidal patients, are techniques used to elicit, question and correct, distorted conceptualisations and beliefs of the external world. An important emphasis should be given to self-monitoring; the use of a thought diary may aid in verifying links between events, thoughts and emotions. Cognitive restructuring is also an important part of therapy. After thoughts have been identified, arguments and evidence supporting and subsequently casting doubts on their reality should be pursued. Finally patients should reach a reasoned conclusion based on available data, both for and opposed to their beliefs.

Behavioural Techniques

Many CBT programs for suicidal patients are based on a system of reward to reinforce desirable behaviours. The reward system may involve relatives as well as friends, but may also involve self-reinforcement, in which the patient rewards themselves. It has been shown that suicidal behaviour can be worsened by inactivity. Therefore, activity scheduling giving importance to pleasurable activities is a fundamental process.

What is the way forward?

Despite all the efforts that have been made during the last century since the publication of the first scientific work by Durkheim (1897), significant progress in this area of ​clinical intervention has been limited. Van der Sande et al (1997), in their literature review (mentioned above), discovered that only four studies that applied cognitive-behavioural techniques were useful in preventing future suicide attempts. However, these studies involved very specific populations: women who suffered from borderline personality disorder (Linehan, Heard, & Armstrong, 1993; Linehan, Tutek, Heard, & Amstrong, 1994) and with low lethality; adolescents (Brent, 1997; Rotheram-Borus, Piacentini, Miller, Graae, & Castro-Blanco, 1994) also with low lethality; and young adults at high risk of suicide (Salkovskis, Atha, & Storer, 1990) but with a very small sample size and lax methodology. On the other hand, Hollon, De Rubeis and Evans (1996), in a more extensive controlled study, found a statistically significant difference when CBT was used as an adjunct to biological treatments, in patients with severe depression, to prevent future relapses. The authors of that study speculated whether CBT, when used as an adjunct to psychopharmacological therapy, could also have a protective effect in decreasing rates of attempted suicide in patients who used more lethal means of suicide. I believe that an increased focus should be placed on studying suicide as an independent clinical syndrome with its own psychopathology and for which, therefore, corresponding specific therapeutic solutions are needed.

Dr Beppe Micallef-Trigona is a Maltese psychiatrist who returned to Malta after working as a consultant psychiatrist with the UK Ministry of Defence (Royal Navy), and previously, as a consultant psychiatrist in the UK National Health Service.